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Theoretical Framework

Internet is currently one of the largest market. Among the various products that are soldonline, pharmaceutical products are of particular interest because of their impact on health. The interest in the market of online pharmacies has been well documented since late '90s. In the early '2000 new studies started addressing what psychological constructs and variables are associated to the purchase of pharmaceutical products online. These early studies call for additional research to explore psychological factors that may influence consumers’ decisions related to the purchase onlineof pharmaceutical products, within a unifying theoretical framework that could allow for a systematic interpretation of psychological constructs linked to this behavior. This framework is provided by the Theory of Planned Behavior and by psychological models that addressed the study of risk perception and of risk propensity. The Theory of Planned Behavior (henceforth TPB) is an economical and comprehensive model accounting for the formation of behavioral intentions as a basis for explaining behavior. It assumes that the proximal cause of behavior is one's intention to engage in that behavior. Intention in its turn depends on the following predictors:

subjective norm (i.e., one's perception of the social pressure put on him/her to engage in the behavior, that is how much those people who are important for the respondent would approve respondent's behavior)

perceived behavioral control (i.e., one's perception of how easy or difficult it is to perform the behavior). An independent variable added to extend the theory is past behavior. However, variables from the TPB do not explain 100% of health related behavior: variables from other theoretical models may complete the predictive power of TPB.

The role of perceived risk has been examined especially as a determinant of consumers choices. Among the major types of domains involving perceived risk, one of particular relevance for health behavior is physical risk, that is the probability that the purchased product will result in a threat to human life. Since purchasing pharmaceuticals online is a behavior representing a risk for health, we believe important to take into account also those aspect of personality that are associated to individual differences in propensity to risk. In the context of consumer behavior it is important the role of risk that the consumer perceives in purchase decisions: a wide range of psychological studies have shown thus that people differ in how they perceive risk. Among the different personality dimensions associated to risk, the dimension of Stimulating RiskTaking seems to be particularly relevant. It refers to rapid, effortless and even automatic behavior, taken as a response to a strong need of immediate sensations and excitement.

Empirical Study

The aims of our study were twofold:

to assess the prevalence of purchasing of pharmaceutical products online in three European Countries, namely Italy, Spain and Portugal

to investigate the impact of different psychological and socio-demographic variables on the future Intention of purchasing pharmaceutical products online

The main socio-demographic variables considered were gender, age and education. The main psychological variables considered were:

Safety Perception, that is, how safe for the healthis perceived the purchase of pharmaceuticals online.

Three samples were considered in the three countries included in the research. Italian sample consisted of 1,000 participants, aged from 18 to 84 years (M = 40 SD = 13), 54% males. Spanish sample consisted of 1,255 participants, aged from 18 to 74 years (M = 38, SD = 12), 50% males. Portuguese sample consisted of 1,000 participants, aged from 18 to 74 years (M = 37; SD = 14), 30% males. Italian and Spanish samples are representative of the total population of adult internet users (at least eighteen years old), that is, Italian and Spanish who used Internet at least once in the last seven days before the research was performed. Online questionnaires were used in order to measure the constructs of interest. To each participant a questionnaire consisting of about 60 items has been administered. The survey was composed by different items investigating different domains. Data were collected in Italy in January 2014, in Spain in April 2014and in Portugal in May 2014. A quota sampling strategy, balanced by geographic area, age and gender was used in Italy and in Spain.

Results

Awareness of medicine purchasing online. The percentage of participants who are aware of the possibility of purchasing medicines online was 72% in Italy, 45% in Spain, and 84% in Portugal. Knowledge of initiatives and events. Participants who were acquainted of initiatives and events aimed at raising public awareness on the risks of buying medicines online were much similar in the three countries, being 21% in Italy, 23% in Spain, 25% in Portugal. Prevalence of medicine purchasing online. Participants who have purchased medicines online were 20% in Italy, 9% in Spain, and 2.5% in Portugal (this lower percentage in Portugal is probably due to the sampling procedures). Medicines for weight loss are by far those that are more purchased in all three countries, followed by medicines against flu, medicines for quit smoking, medicines for chronic pain, and medicine against cholesterol. Medicine for erectile dysfunctions are among the less purchased (2.4% in Italy, 4% in Spain and 2% in Portugal).

Impact of psychological and socio-demographic variables on purchasing pharmaceutical products online. Three regression analysis were conducted considering the intention of future purchase of medicines online as a dependent variable, and psychological and socio-demographic variables as independent variables or predictors. The results of these regression analyses showed that:

Subjective Norm was the main determinant of future purchase intention: the more this behavior is approved by other people important to the participant as far as the issues of health and self care are concerned, the stronger will be the probability of doing this purchase in the future

Safety Perception was the second more important significant predictor of the intention of future purchase: the higher the perception that purchasing medicines online is safe for health, the stronger will be the probability of doing this purchase in the future

Past Purchase Behavior was the third more important significant predictor of the intention of future purchase: the more one has purchased pharmaceutical products online in the past, the stronger will be the probability of doing this purchase in the future

Attitude was the fourth more important significant predictor of the intention of future purchase: the more positively is judged the purchasing of pharmaceuticals online, the stronger will be the probability of doing this purchase in the future

Safety Perception, moreover, resulted the more important determinant of Attitude and of Subjective Norm, thus the higher the perception of the purchase as safe for health, the more positively is judged the purchasing of pharmaceuticals online and the more is approved by other people important to the respondent

Propensity to risk and Perceived Control showed a significant but low effect on Future Purchase Intention only in Italy, so we believe these two effects cannot be generalized and then will not be discussed

the effect Socio-demographic variables was marginal and differed across the three countries. In Italy respondents living in big cities or in their suburbs tend to have purchased more than and to have a stronger future intention to purchase than respondents living in small towns, in country villages or in the countryside. In Spain, male respondents tend to have a more positive attitude toward future purchasing, and to perceive the purchase as a more safe behavior than female respondents. In Portugal no statistically significant differences emerged in past purchase and in future intention due to demographic variables.

Discussions and implications for policy-making

The results evidenced differences in knowledge of the possibility of online purchase of medicines from the three countries: in Spain this is probably due to the different type of market (e.g., widespread distribution of land-based pharmacies on the Spanish territory). There were differences in the methodology of data collection: Italy and Spain are homogeneous; in Portugal it has been used a different methodology. Thus it is difficult to compare Portugal results with those in Spain and in Italy. Knowledge of prevention initiatives and information is too low (around 20-25%) in all three countries: awareness must be increased with communication campaigns on different media (the web, TV, newspapers, wallpapers). From a policy-maker perspective these results evidence that purchasing pharmaceutical products online is a behavior mainly guided by rational beliefs that can be changed, not by impulsive tendencies that are largely irrational. Approval of others, attitude and perception of safety are the most important variables in explaining online purchase: these are important variables to be influenced with communication campaigns aimed at reducing future purchase. Communicating that the product purchased online can have dangerous consequences for health (because the product can be counterfeit; because even if original the product cannot be sold without prescription) may lower the perception of this behavior as safe for health, consequently it could lead to a less positive (or to a negative) attitude toward the behavior, and to the expectation that it will not be approved by relevant others. It is important to capitalize on the role that significant others may have on the purchaser: these are people whose opinion is important for the purchaser, people who are considered as trustworthy when health and health related behaviors are an issue. Physicians, pharmacists but also relatives are fundamental vectors for influencing future purchasing behaviors, and eventually reduce it. This is a fact clearly important from the point of view of those who must make decisions for risk communication.